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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT $,' AN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E. HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 NON-REFUNDABLE PERMIT CALLZUJ `9b.3 -/t)91 FOR INSPECTIONS v �tXPIRES 1 YEAR FROM UATE ISSUEI •(OB ADDRESS 11L�% i ilii �J —CITY/ZIP �/� !rJ-' j 3s 6 CROSS STREET U APN �/�,3qyV , ✓%/ZPARCEL SIZE OWNER NAME ��`� IHL(J Aj �Jp � ( f, 'S , h� L— PHONE�y� - 1� -) vl 4OWNER ADDRESS 1*7 CONTRACTOR/�(��/ PHONE A1.) CONTRACTOR ADDRESS 6 L PA21�L) r" D(2- CITY/STATE/ZIP LICENSE C-42 C-36 OTHER t�', - Z I NUMBER L if EXPIRATION DATE \ �i WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Ll PERC TEST # BUILDING PERMIT # TYPE OF WORK: I I NEW INSTALLATION I I REPAIR/ADE Coordinates X Y LAND USE APPLICATION # IN ENGINEER DESIGNP REPLACEMENT OUT -OF -SERVICE SEPTIC SYSTEM- DESTRUCTION , .�i'� I L I /1fAC_ INSTALLATION WILL SERVE: RESIDENCE i COMMERCIAL OTHER NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: ❑ SEPTIC TANK TYPE/MFG ❑ GREASE TRAP TYPE/MFG DISTANCE TO NEAREST: WELL ❑ LIFT STATION SIZE TYPE OF PUMP ❑ LEACH LINES I LEACHING CHAMBERS E TO NEAREST ❑ E TO NEAREST ❑ 10 Utz lid DISTANCE TO NEAREST ❑ SUMPS WIDTH DISTANCE TO NEAREST ❑ DISPOSAL PONDS WIDTH DISTANCE TO NEAREST ❑ SEEPAGE PITS NUMBER DISTANCE TO NEAREST CAPACITY CAPACITY ft FOUNDATION ❑ PKG TX PLANT # OF LINES WELL ft FOUNDATION It LENGTH WELL ft FOUNDATION ft LENGTH WELL ft FOUNDATION ft LENGTH 1.. WELL ft FOUNDATION ft LENGTH WELL ft FOUNDATION WIDTH WELL ft FOUNDATION gal # OF COMPARTMENTS gal # OF COMPARTMENTS ft PROPERTY LINE It ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) LENGTH OF LINES ft ft PROPERTY LINE ft ft DEPTH ft ft PROPERTY LINE ®® ft ft DEPTH _ A9l=AST ft ft PROPERTY LINE ft ft DEPTH ft ft PROPERTY LINE A'JRft ft DEPTH SAN J ft ft PROPERTY�INLENIfI „�N �OUN7�. ft ft DEPTH ~LTH ps{ ft ft PROPERTY LINE ft I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL WORKERS COMPENSATION LAWS. REQUIRED FOR INSPECTIONS - SIGNED /l V7 TITLE Vi4V)C:-Ul V�G�� DATE Application Accepted By Final Inspection By Character of Soil to Depth of 3 Ft: COMMENTS Date Date FSE ONLY Area mployee ID# $P CIAL PERMIT -Approved by Pit/Sump Soil Character: 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 5/5/17 Received Permit/ WE"IMP . ..,� 5.. - 1.. 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 5/5/17